Mistake Blamed for Surgery Deaths

Published 8:00 pm, Tuesday, January 15, 2002

Associated Press Writer

Two women died during heart surgery after they were mistakenly given an anesthetic instead of oxygen, hospital officials said Wednesday.

The women died after a meter that controls the flow of oxygen during operations was mistakenly plugged into an adjacent receptacle for nitrous oxide gas, a common anesthetic Hospital of Saint Raphael officials said.

The meter was equipped with safety prongs designed to prevent such a mistake. However, one of the prongs was broken.

The first woman, who was in her 70s and described as in poor health, died Friday during a cardiac catheterization, where doctors use a flexible tube to inject dye into the heart to help diagnose problems.

The death "did not originally appear to be out of the ordinary, given the seriousness of that patient's medical condition," said Dr. Charles Riordan, vice president of medical affairs for the hospital.

The death of the second woman during the same type of surgery Tuesday touched off an investigation that found the meter had remained plugged in to the nitrous oxide receptacle, hospital officials said.

The second woman, in her late 60s, was not as sick as the first victim, officials said. They said when her oxygen levels began to dip during the procedure, the flow of the gas was increased and she died on the table.

The hospital notified the Food and Drug Administration and the state health department. It would not identify the employees involved.

Riordan said no disciplinary action is anticipated because a combination of human error, failure to check the oxygen meter and the broken safety prong were all factors in the deaths.

The meter was manufactured by Precision Medical Inc. of Northhampton, Pa. Messages seeking comment were not immediately returned.

FDA spokeswoman Sharon Snider said the agency had not yet received the report on the patients' deaths.

"We take any patient death that could be related to a medical device very seriously, and we would investigate it immediately," Snider said.

The state Department of Public Health brought a team of investigators to the hospital Tuesday to interview staff, review safety procedures and examine equipment.

The state could censure the hospital with a written reprimand, impose a fine, order changes in procedure, or even suspend the hospital's license, said Joan Leavitt, the manager of the department's compliance and licensing unit.

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It is premature to discuss what action the state may take, she said. The investigation is expected to take several days.